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Menstrual suppression: the rhetoric and realities of choice.

Introduction

The public imagination is saturated with references to 'choice', whose semantic origins can be traced to the women's rights and consumer health movements of the 1960s and 70s. In campaigns about reproductive rights, and the rights of women to participate in society outside of the domestic sphere, choice was used in very powerful ways to dramatically shift perceptions of gender roles (cf Friedan 1963; Oakley 1976; Ryan, Ripper & Buttfield 1994; Summers 1975). However, these meanings of choice have since been distorted as the powerful discourse of individual choice has been taken up as a mantle of neoliberalism. This has profound implications for feminist scholarship generally, and for feminist discussions of reproductive technologies in particular. As Rosalind Gill has pointed out, the pervasive emphasis on individual choice leaves no space for critical discussion of behaviours and practices as 'all behaviour ... is understood within a discourse of free choice and autonomy' (Gill 2007: 72). However, feminist and sociological scholars are increasingly problematising choice and have worked to expand critical pockets of debate that challenge such stalwarts of neoliberal language (Beasley & Bacchi 2007; Bulbeck 2001; Ells 2003; Gill 2007; Ringrose 2007). This article builds on this growing body of work by demonstrating how the neoliberal interpretation of choice is employed to put forward a scientific rationale for the use of extended-cycle oral contraception (ECOC) for the purpose of menstrual suppression. It draws on comparative discourse analysis of two fields involved in the debates about menstrual suppression? biomedicine and women's narratives? following the US Food and Drug Administration (FDA) approval of the first ECOC in 2003.

Feminism and choice

The theory and action of feminists around choice and reproductive health during the women's movement in North America, Britain, and Australia have been well documented (Boston Women's Health Book Collective 2005; Broom 1991; Doyal 1983). A dominant focus of the women's health movement was the apparent need for accessible 'information' in order to expand and inform women's choices. Choice has been a powerful bargaining tool for a variety of feminist health campaigns and bioethics debates, for example those about abortion (Ryan, Ripper & Buttfield 1994) and assisted reproduction (Purdy 1998). In particular, choice has come to be intertwined with the notion of information as bioethical accounts have emphasised the importance of not just expansion of choices in women's reproductive health, but of informed choices (Faden, Beauchamp & King 1986).

Such arguments imply that there is an identifiable point at which women are informed enough to be autonomous in the choices they make. Indeed, Frances Griffiths has argued that, however tricky it may be to navigate to such a position, there is such a thing as 'real choice ... when women feel in control' (Griffiths 1999: 480).

Beck, Giddens and Lash (1994) refer to the notion of choice as part of the social process of individualisation where people become their own reflexive project, continually rebuilding themselves and initiating change in ways of living and being, rather than simply reacting to structural forces. This type of approach has been criticised for focussing too much on the idea of individual choice, which can 'depict the individual as solely responsible for making the choices which are then presented as dubious, insufficiently committed or superficial' (Smart & Shipman 2004: 493). Seemingly, the discourse of individual choice goes hand in hand with that of individual responsibility whereby individuals are encouraged to partake in incessant choosing as part of an increasing emphasis on regulatory practices of self-governance (Petersen 1996; Rose 2006). With the availability of more and more options comes a simultaneous expectation on the individual to make choices with the wider 'social good' in mind (Petersen 1996: 48).

In light of this there has been increasing feminist troubling of such rhetoric (Beasley & Bacchi 2007; Ells 2003). Both Chilla Bulbeck (2011; 2001) and Jessica Ringrose (2007) have undertaken important studies of how women engage with feminist perspectives in Women's Studies courses and the disabling effect of choice on such negotiations. Bulbeck demonstrates the ways in which liberal feminist discourses have become normalized to such an extent that other feminist critiques, which seek to discuss structural inequalities, are deemed as having little relevance to students' lives (Bulbeck 2001: 154). Both Bulbeck and Ringrose discuss how the power of individual choice discourses has the effect of undermining any perception of an ongoing need for feminist politics. Similarly, Gill (2007) underlines the importance of feminist analyses that seek to expose and rupture the dominance of choice. She argues that 'we urgently need to complicate our understandings of choice and agency if we are to develop a meaningful feminist critique of neoliberal, postfeminist culture' (Gill 2007: 72). It is to this end that I unpack the ways in which choice is evoked in relation to menstrual suppression and the use of ECOC.

Methods

This paper draws on a qualitative doctoral study examining the notion of medicalisation in the context of the public debates about ECOC in the USA, UK and Australia. In September 2003 the USA Food and Drug Administration approved the first ECOC--Seasonale--for general prescription. By extending the menstrual cycle from 28 days to three months Seasonale reduced the number of periods per year from 13 to four. Since the study was carried out other ECOC regimes have been released onto the pharmaceutical market that are taken continuously for 365 days a year with no break for a scheduled period (McCarthy & Brar 2008). Such new applications of hormonal treatments provide women with the option to suppress their menstrual cycles and thus represent a new site of biomedical intervention with women's bodies. The study engaged with feminist and sociological discussion about the usefulness of medicalisation as an analytical concept (for a fuller discussion of medicalisation and menstrual suppression see Gunson 2010). In so doing, it explored the meanings of agency and choice for women considering menstrual suppression in the current climate of neoliberalism in the West. This 'innovation' was contested across multiple fields, including biomedicine, the pharmaceutical industry, news-media, and weblogs as well as through the lived experiences of women considering menstrual suppression. Data was collected from across these key fields, the timing of which was shaped by key milestones such as the approval and release of the first ECOC in the USA. The fields selected for analysis were those most actively involved in the debates around ECOC during the chosen time frame. This paper will draw on the biomedical and women's accounts to demonstrate how the discourse of choice was invoked in ways that have profound relevance for feminist agendas.

Ethics approval was sought and gained from the appropriate Human Research Ethics Committee. A total of 42 biomedical articles relating to ECOC and published in English language, biomedical journals between 1 January 1999 and 31 December 2005 were collated for analysis. The selection criteria was to include all biomedical literature relating to ECOC following the publication of endocrinologist Elsimar Coutinho's influential book advocating menstrual suppression entitled Is Menstruation Obsolete? (1999). The time frame also deliberately spanned four years prior to, and two years following, Seasonale's release. Qualitative, semi-structured interviews were carried out with 37 women in South Australia who had already chosen to suppress their menstruation (either temporarily or long term) by extending their use of traditional 28 day regimen oral contraption (OC). Participants were recruited through a university press release, which generated local radio and newspaper coverage of the study. Interviewing women in Australia enabled a juxtaposition of the public debates about the approval of ECOC in the USA for widespread use with the personal accounts of women extending their menstrual cycles in a location where such medical legitimisation had not taken place. The primary method of exploring these sets of data from different fields was discourse analysis, taking a feminist poststructuralist approach. All the data was read in its entirety and coded according to the dominant discourses present. The process of coding enabled a grounded theoretical analysis of the data to emerge. Subsequently, the ways in which discourses were taken up in different ways was examined.

Biomedicine, menstrual suppression, and choice

The articles analysed in this study showed there to be a growing pocket of biomedics who argue menstruation to be obsolete due to changes in women's life practices and desires, and who subsequently promote the notion of menstrual suppression (Coutinho 1999; Glasier et al. 2003; Miller & Hughes 2003; Thomas & Ellertson 2000). More recent literature continues this agenda (Sulak 2008), however it is unclear as to whether such a reframing is having a paradigmatic impact on dominant understandings of the menstrual cycle (Seval et al. 2011). Indeed, at the time of Seasonale's release key members of the Society for Menstrual Cycle Research (SMCR) demonstrated resistance to the idea that menstruation is redundant from within the biomedical field (SMCR 2003). The significance of the SMCR will form the basis of a separate article for future publication by the author. Nonetheless, the majority of articles included in the sample were actively engaging in attempts to shift public understandings of the meaning of menstruation, with a common focus on the remoulding of women's attitudes towards its suppression. The central arguments for this were drawn from the work of Coutinho (1999) who tells an evolutionary story to support the idea that women today need not bleed. He argues:

Since antiquity, a woman became pregnant near the time of menarche ... and remained menstruation-free for the rest of her short life, because of continuous cycles of pregnancy and lactation. Regular and recurrent menstruation throughout most of a woman's reproductive years is a fairly recent phenomenon.... Menstruation is an unnecessary, avoidable byproduct of the human reproductive process. (Coutinho 1999: 163)

Glasier et al. (2003) take up Coutinho's argument and posit that women are gradually becoming more accepting of the concept of not bleeding. They also state that large numbers of women who already use 28 day cycle OC, use it to manipulate the timing of their periods. This, they suggest, is evidence that eliminating bleeding is a positive option that some women actively choose (Glasier et al. 2003). Much of the literature supporting menstrual suppression focuses on the negative aspects of menstruation in order to promote ECOC, almost by default. No attention was given to the positive aspects and functions of menstruation or the idea that menstruation is a vital sign of wellbeing (Bobel 2010: 8). The negative aspects of ECOC were also played down, even though trials for Seasonale found women had similar total days of bleeding, but these were classified as breakthrough bleeding or spotting days, not 'periods' (Anderson & Hait 2003). This linguistic reframing masks the reality that ECOC is not necessarily suppressing bleeding but is stopping hormonal cycling.

In support of ECOC, Glasier et al. (2003) state that the notion of the monthly bleed as a sign of a healthy body is a relatively recent cultural attitude that became established as a way to deal with the 'epidemic of menstrual cycles' that have come about due to demographic change. They say that there is 'no medical advantage to menstruation per se. On the contrary, the morbidity associated with menstruation is impressive' (Glasier et al. 2003: 1). Such arguments draw heavily on the neoliberal discourse of informed choice to legitimise the need to promote menstrual suppression to women. Menstruation has a specific history of being culturally constructed as dirty, polluting, and dangerous and there has been much feminist attention paid to this unique and troubling stigmatization of women's bodily processes (cf Bobel 2010; Douglas 1966; Martin 1997). Reinscribing such stigmatization, the explicit labeling of menstruation as an 'epidemic' codes modern women's bodies as out of control and deviant, evoking comparison with other contemporary 'lifestyle' diseases such as obesity and, by default, endorsing urgent medical intervention (Wright & Harwood 2009). In this way, the choice to suppress menstruation is reframed as being in the interests of the greater social good (Petersen 1996; Sanabria 2011). A number of studies (Braunstein et al. 2003; Miller & Notter 2001; Schwartz, Creinin & Pymar 1999) explicitly invoke social responsibility by undertaking cost/benefit analyses of menstruation and suppression. In this context, Schwartz, Creinin and Pymar propose that 'a decrease in use of analgesics and iron supplements and an increase in productivity measured in days of work are other factors that may reduce the overall societal cost [of menstruation]' (1999: 266). The biomedical data acknowledged the interrelationship between what can physically be done in scientific practice (which is defined as measurable and 'true') and secondly, the less predictable, shifting aspect of cultural acceptability of those practices. It is clear that biomedics involved in the development of ECOC felt that its use for menstrual suppression has been scientifically proven as a justifiable practice that women could take-up. However, the most common assertion in biomedical literature is that work has to be done to shift the attitudes of women so that it comes to be seen as a legitimate practice that they will take-up more widely (Glasier et al. 2003). In the pro-suppression biomedical literature ECOC is presented as a new option that women will likely choose if they are provided with sufficient information about its supposed benefits. Simultaneously, this argument has the effect of putting in doubt the validity of women's choices have they not been exposed to what the biomedical authors believe to be legitimate pro-suppression literature.

A third of the biomedical articles (14 of 42) were published in the USA-based journal of the Association of Reproductive Health Professionals (ARHP) titled Contraception. The ARHP is central to the processes of securing legitimacy for menstrual suppression in the biomedical field in the USA, and beyond. In April 2003, predicting the approval of Seasonale, the ARHP and the National Association of Nurse Practitioners in Women's Health (NPWH) joined together to produce a special issue of ARHP Clinical Proceedings specifically on the topic of 'extended regimen contraception' titled Choosing When to Menstruate: the role of extended contraception (ARHP & NPWH 2003: 1). The ARHP Clinical Proceedings provide an overview of a selection of other research on the use of ECOC and menstrual suppression. In particular, it draws on a 1994 article that firmly frames menstruation in evolutionary terms and constructs a link between cancer in women's reproductive organs and frequent menstruation (Eaton et al. 1994). The ARHP and NPWH then go on to summarise other research in a way that explicitly codes menstrual suppression as positive. The authors report findings of a telephone poll which ARHP and NPWH commissioned in 2002, asking 491 women between the ages of 18 and 49 'about their preferences on the frequency and characteristics of menstrual bleeding' (ARHP & NPWH 2003: 4). They compare their results with those of den Tonkelaar and Oddens (1999) and Andrist, Hoyt, Weinstein, and McGibbon (2004), both of which lend support to the idea that women in general are neither dominantly for or against menstrual suppression, but that were it more widely acknowledged as 'acceptable' it would be a more popular practice. Menstrual suppression is presented as having a large number of potential users but needs to be 'officially' endorsed in order to establish its medical legitimacy. In the introductory statement of the ARHP Clinical Proceedings, it says:

Extended regimen contraceptives give women another reproductive health choice; when and whether to experience menstrual bleeding. We are pleased to help advance the research and practice of extended regimen contraceptives through this issue of Clinical Proceedings. (ARHP & NPWH 2003: 2)

This statement makes clear the ARHP and NPWH position on menstrual suppression from the outset. For the ARHP and NPWH, choice is framed in such a way as to mean the availability of as many contraceptive options as possible. The authors take for granted that the reader will accept the expansion of reproductive health choices as a positive development. This frames contraceptive users as 'consumers'. In this instance, imagining choice through a consumerist lens has the effect of shifting understandings of the role of reproductive health professionals. Their role is assumed to expand beyond therapeutic consideration and implementation, to include an obligation to provide access to a wide number of contraceptive options that induce a range of different effects. The implication is that the consumer is then expected to choose from that range according to her own 'preference' of method and effects, engaging with pharmaceutical consumption and, in the process, becoming an 'expert patient' (Fox, Ward & O'Rourke 2005).

The co-chairs of the ARHP and NPWH clinical advisory board both declare themselves to have allegiances with Barr Laboratories, makers of Seasonale (ARHP & NPWH 2003: 15). Whilst these alliances do not necessarily undermine the findings of the ARHP and NPWH, they do demonstrate the inextricable links and overlaps between the development of new biomedical knowledge, drug manufacturers and the 'marketplace', particularly in a privatised health care system as exists in the USA. Choice in this context is densely layered with dominant assumptions about consumption and the need to assert individual control over all aspects of life through consumption. In the ARHP and NPWH journal it is clear that the therapeutic or 'medical' role of menstrual suppression is framed as only one of many factors that influence consumer choice, rather than as the primary consideration. Public debates about OC pills have always included discussions of the physical risks and benefits as well as its so-called 'lifestyle' benefits. But recent shifts, particularly in USA biomedicine to 'advance ... the practice of extended regimen contraceptives' (ARHP & NPWH 2003: 2) bring with them new interpretations of risks/benefits, of so-called consumer desires, and of menstruation, that combine to produce new tensions and contradictions. In particular the approach of the ARHP and NPWH demonstrates a conflation of the meanings of choice that co-opts both the language of women's rights and that of consumerism. This frames menstruation as a lifestyle option that can simply be switched on and off, depending on the individual's (informed) preference. However, the simultaneous coding of menstruation as a modern epidemic imbues the choice to menstruate as morally questionable. In so doing, menstrual suppression is dominantly coded as an act of responsible citizenship (Sanabria 2011).

This analysis of the medical literature found there to be a hegemonic understanding amongst biomedical researchers that they have uncovered a scientific 'truth' about menstruation's obsolescence, and that this should be unilaterally disseminated to women through practitioners and pharmaceutical marketing. By invoking the concepts of informed choice and patient education in this way, much of the biomedical literature on menstrual suppression pre-empts social critique. As Bulbeck (2001) highlights, such a prolific focus on neoliberal discourse normalises a caricatured version of choice in ways that bleed feminist critiques of their political legitimacy (Bulbeck 2001: 154). It is not the intention here to discredit biomedical constructions of menstrual suppression, but instead to explore how they are connected to the embodied experiences of women; to understand choices in context, rather than choice as rhetoric. Thus, in order to provide social and material context for biomedical discourse and in turn engage productively with feminist critiques, it is necessary to examine the lived experiences of menstrual suppression.

Women choosing menstrual suppression

The women who participated in this study through qualitative interviews lived in South Australia. They varied in age between 21 and 57. The women whose narratives are discussed below had all manipulated their traditional 28 day regimen OC to delay or stop their menstrual cycle. Their practices fell loosely into three categories. There were 14 women of the 37 who had run their active pills together to stop menstruation only occasionally in their lives. Another 14 women suppressed their menstruation with OC regularly, in a pattern that gave them three or four periods per year, reflecting that chosen by the manufacturers of Seasonale. The remaining nine took active OC continually all year round with no withdrawal, thus not having a period for some years.

Most women viewed the rhetoric of choice positively and valued being able to access ways to control problematic or inconvenient menstruation. However, their stories also showed that the embodiment of choice is varied and contextual. These narratives showed that agency is generative, in that while accommodating the notion of choice, women themselves reappropriate and redefine the meaning of choice. As Gill states, '[w]omen make the choice to suppress their menstruation in a context where a cleansed and contained body is a "normative requirement" (2007: 71). The cultural norms and expectations around women's grooming and containment have been well documented and feminists have consistently troubled the political and personal implications of body modification practices and medical technologies such as genital modification (Herzig 2009). Such scholarship underlines the need for ongoing discussion that attends to the local, social, and embodied contexts within which women make decisions about participating in such practices. Mol (2008) has suggested there is a need to seek alternative understandings that challenge the dichotomous logic of choice where mechanical actors make decisions. She argues that people engage with biomedicine in fluid ways, sometimes passively accepting care, sometimes actively caring or rejecting care (Mol 2008: 80). Along such lines there have been a number of feminist and sociological scholars who have highlighted the need to move beyond notions of the culturally constructed neoliberal subject (Alaimo & Hekman 2008; Fox & Ward 2006). The process of deciding to suppress menstruation is never a singular choice, nor is it the act of a neoliberal subject simply playing out the role of a responsible consumer. Instead, women described their thought processes and how they assessed the 'risks' of menstrual suppression as simultaneously happening on 'different levels', especially in terms of day-to-day concerns compared to long term planning or desires. Hailey [32 yr old] said:
   I know [the contraceptive pill has] been widely used and tested for
   decades and many women have had no problems being on the pill for a
   long time. I understand the risks and how to minimise them like, by
   not smoking. So on a day-to-day level I have no concerns about
   taking the pill. However, I wouldn't want to do it for all of my
   adult life.


Maeve [28 yr old] said that she worried about the long term effects of OC but that deciding to suppress was something she did in the present moment.
   I worry about the long term effects being on the pill has in the
   back of my mind especially when suppressing menstruation for long
   periods but I still use it to suppress periods as I tend to think
   of now not a few years down the track if something's going to
   happen it will happen regardless.


Like Maeve many women's accounts demonstrated ambivalence in that they experience contrasting feelings simultaneously about the risks associated with hormonal suppression and menstruation. It is not sufficient to say that women's narratives reflect a simple risk/benefit calculation about their practices. Echoing the study carried out by Fox and Ward (2006) on the use of medical technologies such as Viagra, the process of taking up menstrual suppression produced a range of health identities. To draw on Fox and Ward's analogy, some women framed themselves as 'expert patients', some women framed their suppression as an act of resistance, and other women's identities were less explicitly stated. These less explicitly stated identities show how the use of menstrual suppression often occurred out of uncertainty and ambivalence. Interviewees varied in the extent to which they trusted the information given to them by their healthcare professional. Similarly, the degree to which they relied on that relationship for reassurance about the safety and acceptability of their method of suppression differed. Some women, like Verity [23 yr old], were sceptical about the ongoing validity of safety claims:
   I am not one hundred per cent confident that it is safe. I know
   there are no major worries now about it but there are always
   findings where certain drugs that were perceived safe are
   discovered not to be.


In contrast to those who continued to suppress menstruation despite concerns, Clare [23 yr old] told of how her concerns gradually became more pertinent, eventually overtaking convenience and leading her to stop the practice of suppression. In the past Clare had found suppressing menstruation to be convenient but had recently started to question the impact of synthetic hormones on her body and was particularly concerned about her personal risk of breast cancer. This account demonstrates the similarities of menstrual suppression with women's experiences of Hormone Replacement Therapy. Griffiths (1999) argued that women's use of HRT was fraught with complexity and uncertainty around symptoms, risk information and the patient/practitioner relationship. Indeed, there are numerous parallels with HRT, given that long term trials are yet to be carried out on the use of ECOC. Biomedical promotion of ECOC arose in the aftermath of findings that the hormonal treatment of menopause using HRT significantly increases the 'risk of adverse event' (Mayor 2002: 673). These findings subsequently led to a long term trial of HRT being stopped early and have significantly reduced levels of HRT use (White 2002: 987). Echoing the accounts of women interviewed by Griffiths about HRT, Clare described herself as gradually becoming more conscious about a lack of evidence regarding continual pill use. This had led to a shift in that she no longer felt confident enough about the amount of research carried out to feel 'safe' taking OC to suppress her menstruation:

Jessie: What would it take for you to change your mind about suppressing your periods again? Could you describe anything that would make you decide to suppress your periods again?

Clare: Long term prospective studies involving large numbers of people showing no negative effects of suppressing periods would make me reconsider, but this seems to be a long way off. If negative effects were found or even suggested I would not consider suppressing my periods, and in the absence of any information like this I've decided not to anyway, to be on the safe side.

These comments by Clare show how the meanings she attached to risk shifted quite dramatically to a point where she felt she could no longer consider suppressing her menstruation unless she could be certain of a total absence of any negative side effects. In contrast, Marsha, [37 yr old] whose periods exacerbated her experience of Chronic Fatigue Syndrome, suppressed her menstruation continually with OC. Marsha described how she had been given conflicting advice from different practitioners. Whilst she had concerns about the safety of taking OC long term she conceptualised her suppression as the least drastic way of minimising the problematic nature of her menstruation:

Marsha: I have multiple chemical sensitivity as a result of the Chronic Fatigue Syndrome I wasn't prepared to have any other chemical, er you know, as in medication, erm put into my system. So I decided to go for the conservative option in just taking the pill. [...] I know that [suppression] is a short term option and that I need to consider what I'm going to do in the long term, because the gynaecologist tells me that there's an increased risk of breast cancer, in taking the pill long term. And I already have a risk, a family risk, an inherited risk of breast cancer. Erm, however, the endocrinologist who I see tells me that he's not worried about increased risk. You know, there's research but it depends on how you look at it. One doctor's telling me it is quite a risk, another doctor's saying it's not really much of a risk [laughing]. Erm, I am not prepared to, to have surgical intervention and medical intervention if I can help it. So this seems to be as I said a conservative option but it is working, for now.

Marsha's conceptualisation of OC as benign or as relatively harmless because the risks of taking or not taking balance each other out has resonance in many other women's narratives. In particular, there were some women who expressed no concerns about risks associated with hormonal methods of suppression as there was an assumption that if OC is 'on the market' and has been prescribed by a doctor then it must have been tested and shown to have minimal risks. When speaking about hormonal methods of suppression, there was a sense among these women that as OC had been available for so many years, any side effects would already have been discovered. Furthermore, the volume of women on OC combined with the number of years that it has been available was considered testament to its safety. GPs often played a very important role in reassuring that this was the case, as with Joy [42 yr old]:

Jessie: To what extent were you concerned about any other health issues when you decided to suppress your periods?

Joy: Very concerned. Had heard something about breast cancer issues. But my doctor assured me that there were no side effects to worry about. [...] As it has been on the market for forty odd years with no drastic health concerns, I felt confident in taking for twenty odd years.

In a similar way, Ellie [25 yr old] had experienced concerns which she described as being allayed by her doctor. However, she outlined the way in which her doctor framed the level of risk as being dependent on Ellie's responsibility to take part in preventative practices:

In the past I have talked to my doctor about the long term use, I had concerns mainly about osteoporosis and cancer, but she assured me that there was nothing to be worried about as long as I had routine check-ups, including blood pressure checks, pap smears, breast self examinations etc.

In this way the understanding of risk is shifted from being an external one posed by the effects of long term use of OC to being an internal risk, or embodied risk (Kavanagh & Broom 1998: 437), where it is Ellie's body that must be kept under surveillance, not OC. This shift has significant effects in terms of the health identity that Ellie is able to construct for herself, as a responsible consumer. She understood herself to be making the most of the 'positive effects' of OC, as opposed to someone who is at risk from it. The slippage from external risk to embodied risk has important effects in that the threat is then understood to come from within (Kavanagh & Broom 1998: 442). In this process, Kavanagh and Broom state that this can have the effect of magnifying the self/body split where the self is separated from, and in a continual 'battle' to control, the body.

Discussion

In biomedical accounts of menstrual suppression the notions of individual and informed choice, as well as consumer rights and responsibilities are continually (and often contradictorily) reiterated in ways that seemingly verify menstrual suppression as being a rational decision for women. The narratives of the women who were participants in this study demonstrated accommodation as well as uncertainty and scepticism. In so doing, they constructed a range of health identities that both appropriated and contested dominant understandings of 'choice', reflecting the complex intersections of social, cultural and embodied constraints when taking up medical technologies. Women articulated fluidity in the extent to which they felt concerned about risk at different times and in different contexts. They expressed both trust in and scepticism of the information about risk provided by medical professionals, and felt especially ambivalent when it came to information about the different risks of cancer. The extent to which women felt such information was of relevance to them depended on whether personal or familial experiences made cancer or other health risks more salient to them. Similarly, the local, everyday context in which participants considered menstrual suppression transformed the way in which they invoked a sense of moral responsibility in relation to the consideration of implied risks.

Women frequently drew on dominant understandings of choice as justification for their decision and as a caveat that different women's choices were equally valid. In these accounts the rhetoric of choice stands alone, unquestioned, as 'going without saying'. Nevertheless, choices could be deemed as valid, invalid, or as resulting from uncertainty.

This unquestioning declaration of free choice, with the simultaneous ranking of legitimate choices, needs ongoing problematisation (Gill 2007; Jacques & Radtke 2012). The ways in which participants negotiated discourses of risk and choice in the context of menstrual suppression validates the need for nondualistic thinking about the ways in which women take up reproductive technologies. To frame women's narratives through the risk/benefit dichotomy would suggest that their stories demonstrate bipolarity and irreconcilability. This would have the effect of perpetuating a focus on the need for more information in order that women are able to stand firmly on 'one side' or other of constructed, conflicting categories. Instead a more complex understanding of the fluidity of women's deciding acknowledges the ways in which women continually or intermittently reassess their menstrual suppression practices. Only rarely do decisions occur in a singular moment or in a way that remain unchanged or intractable. These stories of choosing, rather than 'choice', have personal, localised and embodied contexts. This means that a focus purely on risk/benefit analysis as a firm, dualistic concept, whilst having more salience in some narratives that others, is a much too simplistic, rigid and polarised way of framing women's process of deciding about their menstrual suppression practices. Rather, discourses of risk are transformed through the everyday experiences of these women. Privileging the biomedical and evolutionary constructions of menstrual suppression without situating the phenomena in women's lived contexts neglects the materiality of women's bodies and denies the relationship between technical and social. Neither, as many feminists have argued, is it enough to simply 'add in' women's accounts as 'the truth' (Gill, 2007: 77).

At an ideological level women in this study subscribed to the rhetoric of individual choice, but this had little traction in the context of their own narratives of choosing to suppress menstruation. Day-to-day embodied experiences and concerns regarding risks of both menstruating and not menstruating, of pregnancy, infertility, and of cancer were much more salient in framing their decisions. This would suggest that biomedical assertions that women simply need re-educating about what is natural or normal are misplaced. Whilst, undoubtedly the innovation of ECOC is shifting the discursive contexts of women's decision-making, I propose that framing ECOC as a new consumer option is, in itself, unlikely to convince women to suppress as a lifestyle option. The stories of South Australian women's experiences of menstrual suppression indicate that what is needed is not 're-education' of women, but clearer, personalised communication between health practitioners and women about the short and long term impacts of extending OC use on contextualized, embodied lives. Similarly, marketing menstrual suppression as a postfeminist act of emancipation for women does not reflect the realities of women's contraceptive decision-making. It relies on tired caricatures of feminism in a way that negates productive critique about the impact of health technologies on women's lives. These narratives suggest a need for more subtle readings of the ways women engage with medical technologies and biomedicine, perhaps, as Mol (2008) suggests, focusing on the relations of care rather than the rhetoric of choice. More nuanced and productive dialogue with biomedicine are needed to move discussions of health technologies beyond choice in order to consider their real impact (positive, negative and uncertain) on women's wellbeing across the lifecourse.

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Further information

Dr Jessica Shipman Gunson is a medical sociologist from the UK. She completed her PhD at The University of Adelaide and then held an ESRC Postdoctoral Fellowship at the University of Edinburgh. She is currently a research fellow to The University of Adelaide in Gender Studies and Social Analysis. Jessica is a member of the Fay Gale Centre for Research on Gender and the preparation of this article was supported by a Fay Gale Early Career Fellowship.
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Author:Gunson, Jessica Shipman
Publication:Outskirts: feminisms along the edge
Article Type:Essay
Geographic Code:4EUUK
Date:Nov 1, 2012
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